RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00665
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040916

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E4, Combat Engineer, medically for “rotator cuff tear and impingement of the right shoulder” with a disability rating of 20%.

CI CONTENTION:  His right shoulder, cervical spine and both wrists continue to impact daily activities.  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting or non-compensable.  Any conditions outside the panel’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition(s) at the time of separation.  The panel has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The panel gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20040720	VARD - 20050118	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Rotator Cuff Tear…Right Shoulder	5201	20%	Rotator Cuff Tear…Dominant	5201	20%	20041102	
Minimal DJD of the Cervical Spine	Not Unfitting	Degenerative Changes Cervical Spine	5003	10%	20041102	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

Right Shoulder Rotator Cuff Tear and Impingement.  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right (dominant) shoulder condition began in February 2003 while training in the when he slipped on ice and fell on his right arm.  Neuroimaging in March 2004 showed a tear involving the anterior –inferior portion of the glenoid labrum (rotator cuff) with mild acromial impingement.  Orthopedics determined surgery was not appropriate at the time, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  

At the 5 February 2004 primary care clinic examination on, 8 months prior to separation, the CI was managing his pain with narcotic medication as non-steroidal anti-inflammatory medication did not alleviate his symptoms.  Physical examination showed range of motion (ROM) at less than 90 degrees (planes of motion not specified by the examiner).  There was tenderness at the shoulder joint and weakness of the abductors in the right shoulder.  Neer and Hawkins tests were positive (evidence for painful motion).  

During the March 2004 MEB examination (recorded on DD Forms 2807-1 and 2808) 6 months prior to separation, the CI reported right shoulder dislocation while sleeping as well as numbness and tingling in the right shoulder and arm which radiated to the right hand.  Physical examination recommended physical therapy (PT) for ROM of the right shoulder and a U3 profile.  The 21 April 2004 PT examination, 5 months prior to separation, documented flexion of 100 degrees (normal 180) and abduction of 62 (normal 180).  

The 21 May 2004 MEB NARSUM examination, 4 months prior to separation, noted complaints of constant stabbing pain in the right shoulder, 8/10 in intensity.  The pain worsened with any movement lasting more than 5 minutes and improved with rest and medication.  Physical examination reiterated the ROM measurements found at the PT examination as documented above.  Tenderness was noted over the anterior and posterior portions of the right shoulder.  Painful motion was documented.  The examiner had difficulty assessing shoulder stability with load and shift testing as the CI could actively subluxate the shoulder and relocate it.  Upper extremity motor strength, sensation and reflexes were normal.

At the 28 October 2004 VA Compensation and Pension (C&P) evaluation, 1 month after separation, the CI reported pain in the right shoulder with any repetitive movement.  Lifting the shoulder above 90 degrees caused pain which prevented ROM movement beyond this point.  He used no brace or assistive device.  He denied instability with daily activities.  He could walk as far as he desired and denied current treatment of any kind nor did he experience any incapacitating episodes.  Since his discharge, the CI was unable to work due to right shoulder pain.  Physical examination showed no instability from Sulcus and apprehension tests.  There was tenderness over the acromioclavicular (A/C) joint.  Rolling on his right side, the CI could feel popping in the A/C joint.  The CI was unable to perform repetitive movements against forward flexion or abduction.  The examiner surmised the CI was guarding on the examination as he was able raise his arm to 90 degrees without pain.  ROM measurements were recorded as flexion and abduction 100 degrees, respectively.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder condition 20%, coded 5201 (arm, limitation of motion), citing pain on motion, abduction limited to 60 degrees and instability with strenuous use.  The VA also rated the right shoulder condition 20%, coded 5201 (arm, limitation of motion), based on the C&P examination 1 month after separation, citing arm motion limited at shoulder level.

The VASRD §4.71a threshold for rating for ROM impairment (code 5201, arm limitation of motion) is “at shoulder level” (approximately 90 degrees from the side), and the VA examination proximate to separation demonstrated motion limited to this level.  The panel considered this examination as having the highest probative value given it was the closest to the date of separation, was the most VASRD-compliant and the most thorough examination in evidence in this regard.  The next higher 30% rating for the dominant arm requires motion limited to “midway between side and shoulder level.” However, examinations did not reflect this degree of limitation.  There was no malunion with marked deformity or frequent episodes of recurrent dislocation of the humerus to justify a higher rating under the 5202 code (humerus, other impairment of), and no higher ratings available under the 5203 code (clavicle or scapula, impairment of).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the right shoulder condition.  

Contended PEB Condition:  Minimal Degenerative Joint Disease (DJD) of the Cervical Spine.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled, implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the right shoulder condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended minimal DJD of the cervical spine condition, the panel unanimously recommends no change from the PEB determination as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160912, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170016914, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,					      
						      					
Enclosure